Journal of Sport Rehabilitation, 2015, 24, 419  -420
http://dx.doi.org/10.1123/JSR.2014-0208a
© 2015 Human Kinetics, Inc.
Commentary on Cheatham et al, “Postoperative
Rehabilitation After Hip Arthroscopy:
A Search for the Evidence”
Maureen K. Dwyer
In “Postoperative Rehabilitation After Hip Arthroscopy:
A Search for the Evidence,” Cheatham et al1 sought to
systematically review the available evidence regarding
postoperative rehabilitation programs for patients
undergoing hip arthroscopy. I commend the authors for
addressing a grossly understudied topic and presenting a
synopsis of the limited evidence in this area. I appreciate
the opportunity to comment on this article, and I will
direct my comments to a few key issues that I feel the
readers should consider when reviewing this article
and interpreting the results for application in a clinical
setting. The issues I will address are the heterogeneity
of the surgical procedures included in the review, the
interpretation of the inclusion criteria for the studies in
the review, and caution on the generalizability of the
results and clinical recommendations.
Arthroscopic treatment of intra-articular and
extra-articular hip pathologic conditions has increased
exponentially in the past decade. However, with the
expansion in the number and type of conditions that
can be successfully treated with this minimally invasive
technique, hip arthroscopy has become an umbrella
term under which very different procedures are grouped.
The studies included in this review all examined a
postoperative rehabilitation program for patients
undergoing arthroscopic treatment for femoroacetabular
impingement (FAI) with or without concomitant labral
injury, and this should be the only subset of patients
treated with hip arthroscopy in which the findings of
this review may be applied. It should be noted that the
extensiveness of the procedures varied between the studies
reviewed, thus making it difficult to apply the findings
from the rehabilitation protocols. For example, the study
in which outcomes after a comprehensive rehabilitation
program after hip arthroscopy were reported for a cohort
of patients did not provide any details regarding the
surgical procedures for patients included in the analysis.2
Therefore, the descriptors for the surgical procedures
Dwyer is with the Kaplan Joint Center, Newton Wellesley
Hospital, Newton, MA. Address author correspondence to
mkdwyer@partners.org.
COMMENTARY
included in Table 2 reviewing the specifics for the
included studies in the review are not accurate for Spencer
et al and can be easily misinterpreted as a consistent
procedure for all patients. This is very important, as
Spencer et al describe different rehabilitation programs
for patients who undergo different surgical procedures.2
The lack of details regarding which surgical procedures
were performed on the patients included in the outcomes
analysis, as well as the potential lack of consistency in the
rehabilitation programs used for these patients, greatly
limits our ability as readers to interpret the successfulness
of the rehabilitation program described. While Cheatham
et al allude to the difficulty in comparing studies that
assessed a rehabilitation program in patients undergoing
different surgical procedures in their Limitations section,
this also could have been emphasized throughout the
synthesis and discussion sections to provide the reader
with accurate information from which to evaluate the
findings. In addition, in my opinion, the paucity and
lack of consistency between the included studies make
understanding the rehabilitation outcomes much more
challenging.
A total of 6 studies were included for analysis in
the review. The authors state that the inclusion criteria
were being
peer reviewed, English-language publications,
investigations that compared a postoperative hip
arthroscopy rehabilitation program to usual or
standard care, investigations that compared 2 different
types of rehabilitation programs, and case reports and
series that described a postoperative rehabilitation
program.
All studies met the last inclusion criterion, in that all
were case studies or series that described a rehabilitation
program after arthroscopic treatment of the hip. Cheatham
et al1 then defined the postoperative rehabilitation program
as “a structured rehabilitation program within the scope
of a rehabilitation professional and included interventions
such as manual therapy, therapeutic exercise, functional
activity, sport-specific training, and modalities.” While
this definition was applicable to 4 of the 6 studies, neither
Reiman et al3 nor Boykin et al4 described a structured
419
 420  Dwyer
rehabilitation program. Boykin et al did provide a
reference to a program that was described in another study
included in the review (Philippon et al5). However, that
program was created for a professional football player
who presented with persistent pain after conservative
treatment for hip subluxation and femoral-head fracture
and who underwent subsequent arthroscopic treatment for
chondrolabral damage and FAI. On the other hand, the
case study by Boykin et al described a professional soccer
player with persistent pain after an adductor-tendon repair
who underwent subsequent arthroscopic treatment for
chondrolabral damage and FAI, along with a second
adductor longus tendon repair. These 2 patients would
and should have different restrictions postoperatively, and
the vastly different requirements of their sport, combined
with the additive tendon repair in the soccer player, should
have resulted in significant alterations to the previously
published protocol. These were not detailed in the Boykin
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et al article, and, thus, care should be taken in interpreting
the findings from this article and applying them to an
isolated hip-arthroscopy population.
The case study by Reiman et al3 did not reference
a rehabilitation program, nor did it provide specifics
of the program used for their athlete. They did provide
general, basic rehabilitation guidelines (ie, progressive
strengthening, pain-free range of motion, progression
to resisted exercises, proprioception and balance, and
sport-specifics); however, these guidelines can be applied
to any musculoskeletal injury at any joint. An important
question would be, “Could a rehabilitation professional
apply the rehabilitation program, as described, to a patient
after hip arthroscopy for treatment of FAI and associated
chondrolabral pathology? Is the program specific to the
treatment of the condition of interest?” If the answer is
yes, then it provides a structured rehabilitation program
that clinicians can critically pursue. In the case of
Reiman et al, it could be argued that it is not a structured
rehabilitation program but, rather, general guidelines.
As the objective of this review was to evaluate the
available evidence regarding postoperative rehabilitation
programs specific to hip arthroscopy, this study does
not provide adequate information from which to draw
clinical recommendations or conclusions. This brings
us to a more important point in rehabilitation research.
It is important for authors to provide enough detail that
clinicians could easily incorporate the rehabilitation
program. While Cheatham et al sought to report on all
the available evidence, the lack of completeness of the
published rehabilitation programs and possibly not-
strict-enough inclusion guidelines lead to difficulties
JSR Vol. 24, No. 4, 2015
with synthesizing the data to provide accurate, valuable
clinical recommendations.
Based on the available evidence, Cheatham et al1
generally recommend a 4- to 5-phase rehabilitation
program with a period of initial restriction in weight
bearing and progression to return to sport at 3 to 6
months. Given the low quality of evidence supporting
a specific rehabilitation program, this is an appropriate
recommendation. However, I would further suggest
that this recommendation be limited to specific athletes
(football and soccer) who underwent arthroscopic
treatment for FAI and chondrolabral damage. These are
the only populations and specific surgical procedures
for which a structured rehabilitation program has been
described with a successful outcome. They may not
be appropriate for other conditions treated with hip
arthroscopy (eg, isolated labral lesions, dysplasia, and
soft-tissue conditions) or other patient populations.
Furthermore, extreme caution should be taken when
applying the published rehabilitation programs to a
specific patient, and the reader should heed the advice of
Cheatham et al to “individualize the treatment according
to the surgical procedure and surgeon recommendations.”
In conclusion, I commend the authors for investigating
an area of rehabilitation that needs continued development.
The identification of rehabilitation evidence is paramount
to ensuring that patients’ outcomes can be maximized.
References
1. Cheatham SW, Enseki KR, Kolber MJ. Postoperative reha-
bilitation after hip arthroscopy: a search for the evidence.
J Sport Rehabil. 2015;24(4). http://dx.doi.org/10.1123/
jsr.2014-0208
2. Spencer-Gardner L, Eischen JJ, Levy BA, Sierra RJ,
Engasser WM, Krych AJ. A comprehensive five-phase
rehabilitation programme after hip arthroscopy for femo-
roacetabular impingement. Knee Surg Sports Traumatol
Arthrosc. 2014;22(4):848–859. PubMed
3. Reiman MP, Cox KD, Jones KS, Byrd JW. Lumbo-pelvic-
hip complex pain in a competitive basketball player: a case
study. Sports Health. 2011;3(1):70–72. PubMed
4. Boykin RE, Stull JD, Giphart JE, Wijdicks CA, Philippon
MJ. Femoroacetabular impingement in a professional
soccer player. Knee Surg Sports Traumatol Arthrosc.
2013;21(5):1203–1211. PubMed
5. Philippon MJ, Christensen JC, Wahoff MS. Rehabilitation
after arthroscopic repair of intra-articular disorders of the
hip in a professional football athlete. J Sport Rehabil.
2009;18(1):118.